A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?

Placing a sign on the client's room door indicating fall risk.

b. Encouraging the client to use the call bell for assistance.

Providing a nonskid mat on the floor beside the client's bed.

Ensuring the client has adequate lighting in the room.

Answer and Explanation

The Correct Answer is B

nswer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.

Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.

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Correct Answer is ["C","E"]

Explanation

Choice A reason:

Chloride is not a major electrolyte that is affected by diabetic ketoacidosis (DKA) Chloride levels may be low, normal or high depending on the acid-base status and hydration of the client. Therefore, chloride is not a priority electrolyte to monitor for signs of imbalance.

Choice B reason:

Phosphate is also not a major electrolyte that is affected by DKA. Phosphate levels may be low due to insulin therapy or high due to renal impairment, but these are not directly related to DKA. Therefore, phosphate is not a priority electrolyte to monitor for signs of imbalance.

Choice C reason:

Bicarbonate is a major electrolyte that is affected by DKA. Bicarbonate levels are low in DKA due to metabolic acidosis caused by the accumulation of ketones in the blood. Low bicarbonate levels can lead to symptoms such as nausea, vomiting, abdominal pain, confusion and coma. Therefore, bicarbonate is a priority electrolyte to monitor for signs of imbalance.

Choice D reason:

Sulfate is not a major electrolyte that is affected by DKA. Sulfate levels are not routinely measured in clinical practice and have no significant role in DKA. Therefore, sulfate is not a priority electrolyte to monitor for signs of imbalance.

Choice E reason:

Potassium is a major electrolyte that is affected by DKA. Potassium levels can be high or low in DKA depending on several factors such as insulin therapy, fluid replacement, renal function and acid-base status. High or low potassium levels can cause cardiac arrhythmias, muscle weakness, paralysis and respiratory failure. Therefore, potassium is a priority electrolyte to monitor for signs of imbalance.

A. Hyperglycemia B. Hypoglycemia C. Hypertension D. Hypocalcemia

Correct Answer is B

Explanation

The correct answer is choice B. Hypoglycemia.Hypoglycemia is a condition where the blood sugar level is too low, which can affect the brain function and cause symptoms such as jitteriness, poor feeding, and seizures.Hypoglycemia is common in newborns, especially in preterm, small for gestational age, and infants of diabetic mothers.

Choice A is wrong because hyperglycemia is a condition where the blood sugar level is too high, which can cause dehydration, increased urination, and ketoacidosis.Hyperglycemia does not usually cause seizures in newborns.

Choice C is wrong because hypertension is a condition where the blood pressure is too high, which can cause damage to the blood vessels and organs.Hypertension can cause seizures in older children and adults, but it is rare in newborns.

Choice D is wrong because hypocalcemia is a condition where the calcium level in the blood is too low, which can affect the nerve and muscle function and cause symptoms such as twitching, spasms, and tetany.Hypocalcemia can also cause seizures in newborns, but it is less common than hypoglycemia.

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A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetic ketoacidosis and is receiving intravenous fluids. Which of the following electrolytes should the nurse monitor closely for signs of imbalance? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

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Correct Answer is B

Explanation

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